It’s easy to view Medicare for All and Strangers without paperwork through the lens of faith.  “When I was sick… you visited me.”  No mention of citizenship here! Maybe Jesus would say we are all citizens of the Kingdom.  We can legislate morality—we do it all the time.  What we can’t legislate is God. We can’t legislate Love.  The politics of healthcare, minus God/Love, is a little more complicated.  Here’s my attempt to reconcile Medicare for All, including the Stranger, with my working politics.

I’m not going to repeat the reasons national health insurance would be a common good. The short version:  providing publicly funded health insurance to everyone here is the best way to improve the cost-effectiveness and quality of our healthcare system.  If you don’t agree with this, I’m going to keep arguing with you!  Bring it on.  My daddy didn’t call me stubborn for nothing.

However, I committed recently to work towards positions that don’t restrict the freedom of any particular person unnecessarily.  To do this, I tried out three “me” perspectives—patients who don’t want to use national health insurance, doctors who don’t want to be paid with it, and insurance company executives.

I’ll be an insurance company executive first, because the other perspectives build on that.  Had to put on some fancier clothes, right off the bat!  As this person, I don’t see how it is justice for the State (We the People) to take my job IF not completely necessary to protect the liberty of others to access the common good of national health insurance.  The argument of single payer advocates has been that as long as I am around, public insurance won’t work.   I can think of one way it would.  Don’t allow any elected/ appointed official or public employee to keep their jobs if they buy my product for themselves or their dependents.  Don’t give any State funding to a business or person that buys my product or employs anyone who does.  Make all campaign financing public only, so that I can’t monetarily influence politicians.  Don’t pay any doctor or hospital out of public money if they also take my money. And stop spending any taxpayer money regulating/ monitoring my business.  Caveat emptor. If I still get in the way of public insurance, I guess I’ll have to get another job.

Next I’ll be a person who doesn’t want to use the national health insurance I help pay for.  Fair enough—I already pay for public schools my kids don’t use. No vouchers, BTW–vouchers don’t square with a philosophy that we all have to contribute to majority-determined common goods. If private insurance is illegal, I can pay medical costs out of pocket if I want to.  If it is legal, I can buy it except under the conditions above.  I am free to leave public employment if I don’t like those rules.

Finally, I will be a doctor who doesn’t want to take national health insurance payment.  No problem—I don’t have to.  There will be some rich folks out there who want to pay me as a concierge or buy high-priced private insurance.  I’m worried about having to compete for the few who will do that, but if it doesn’t work I can switch to the public plan.

Whew, tired of the fancy clothes!  Back in my blue jeans.  Leaving the door open for a few die-hard market-based medicine folks isn’t going to affect us too much.  Think about it—when have we ever been able to keep the rich from getting extra?  It isn’t worth our time to bother with that stuff. We can make restrictions so stringent it wouldn’t rise to the level of a worrisome two-tier system.

Finally, why provide public health insurance to the Strangers among us? For the same reasons, moral and financial, we should provide it to citizens.  It is more cost-effective to cover folks on the front end, in one large risk pool, than to pay for uncompensated care later. As for getting fair contribution, two-thirds of undocumented immigrants already have payroll taxes deducted with fake social security numbers.  We could do even better by quickly issuing temporary guest visas, while we figure out a better way to manage our immigration process and borders.  The only reason not to include everyone?  Plain old meanness.

Today we celebrate the 45th anniversary of the enactment of Medicare. Events are happening across the nation to mark this significant occasion, and yesterday I and about 10 other single-payer health reform advocates walked the halls of Congress and distributed literature to underscore its importance.

Medicare is a true American legacy which has brought health security to many of the most vulnerable members of our society. Because of Medicare, fewer senior citizens are living in poverty. Because of Medicare, health disparities which are growing in younger populations begin to decline after the age of 65. Medicare serves as a model of a universal (for those 65 and older) health system which operates with significantly lower administrative costs as compared to commercial health insurance so that a greater proportion of Medicare dollars pay for direct patient care.

During the recent health reform process, it was puzzling to health advocates to hear members of Congress and the president say that we must keep what works and fix what doesn’t and then see them keep what doesn’t work – commercial insurance. It was puzzling to hear legislators say that we needed to keep the American legacy of employer-sponsored health insurance while they ignored the true American legacy of Medicare.

We took every opportunity to let legislators know that the most effective solution to our health care crisis is to improve and expand a Medicare-like health system to everybody. To the detriment of the people in this nation, while the single-payer movement did grow, our arguments were largely ignored by Congress. The result was increased privatization of health care with its inherent inequities and soaring costs.

Now that a health bill has passed, we face a new challenge altogether. Instead of pushing to expand Medicare, we will have to struggle just to keep our current Medicare, and other social insurances, from being further weakened and privatized. This is a struggle that must not be ignored. We cannot cede any more ground to those who profit at the expense of our human lives.

The president appointed a new commission in April of this year, close on the heels of the passage of the health bill. Known as the National Commission for Fiscal Responsibility and Reform, this group of 18 is packed with and sponsored by those who will gladly use this opportunity to gut our feeble social safety nets. The same marketing tools used so successfully in the health reform process are being employed again: scripted public events used to create the illusion of popular support, public hearings designed to give the appearance of public input and co-optation of progressive institutions in support of neoliberal policies.

The single-payer movement has once again, come together to stand united to oppose the actions of the deficit commission. Four representatives of organizations who are members of the Leadership Conference for Guaranteed Health Care (LCGHC) testified at the deficit commission public hearing in June. However, given the extent of influence being wielded by the billionaire Peter G. Peterson Foundation, it is unlikely that our testimony will influence the commission members.

Our greatest strength as a movement is to hold our legislators accountable by urging them to oppose changes that weaken Medicare, Medicaid and Social Security. To that end, members of the LCGHC spent July 29 walking the halls of Congress. We delivered a letter from the LCGHC, copies of our testimony to the commission, a pledge for members to sign and information about single payer to each of the 435 members in the House and to most of the senators.

In addition, we met with staff in the offices of the co-chairs of the Congressional Progressive Caucus to present them with nearly 1,000 postcards signed by people from across the nation asking them to oppose cuts to Medicare and instead to create improved Medicare for All. We asked that the caucus make a public statement confirming their commitment to not only oppose such cuts, but to actively work to defeat such recommendations.

The deficit commission is charged with the task of submitting their plan to Congress in early December and Congress has committed to vote on their recommendations. The timing of these events has been arranged to occur after the November elections when there will be a lame duck Congress. Such timing makes the task of holding elected officials accountable more difficult but it remains crucial that we attempt to do so.

The struggle for health justice will go on. We must plan now for the future. For this reason, I urge you to meet with your member of Congress and senators during the August break. They will be campaigning in their home districts. You can find information to use in these visits at www.pnhp.org. Ask your legislators to sign the pledge available at www.healthcare-now.org. Publicize the results. And let your legislators know that you will be watching. If they pledge to oppose cuts before the election and then turn around and vote for cuts, no matter what excuse they give, then you must pledge to withhold your vote for them in the 2012 election.

This is the power that we the people possess: the power of the vote. And having the courage to use this power, this tool, at this point in time will bend the arc of justice to the needs of the people of this country.

So, on this day of celebration, Medicare’s 45th, please pledge to yourself to be a defender of our much needed social insurance programs. Step up and join with us to preserve and protect Medicare, a true American legacy.

Margaret Flowers, M.D., is congressional fellow for Physicians for a National Health Program (www.pnhp.org).

Documents reveal AT&T, Verizon, others, thought about dropping employer-sponsored benefits

By Shawn Tully

Fortune
May 6, 2010

The great mystery surrounding the historic health care bill is how the corporations that provide coverage for most Americans — coverage they know and prize — will react to the new law’s radically different regime of subsidies, penalties, and taxes. Now, we’re getting a remarkable inside look at the options AT&T, Deere, and other big companies are weighing to deal with the new legislation.

Internal documents recently reviewed by Fortune, originally requested by Congress, show what the bill’s critics predicted, and what its champions dreaded: many large companies are examining a course that was heretofore unthinkable, dumping the health care coverage they provide to their workers in exchange for paying penalty fees to the government.

That would dismantle the employer-based system that has reigned since World War II. It would also seem to contradict President Obama’s statements that Americans who like their current plans could keep them.

AT&T produced a PowerPoint slide entitled “Medical Cost Versus No Coverage Penalty.”

A document prepared for Verizon by consulting firm Hewitt Resources stated, “Even though the proposed assessments [on companies that do not provide health care] are material, they are modest when compared to the average cost of health care,” and that to avoid costs and regulations, “employers may consider exiting the health care market and send employees to the Exchanges.”

Kenneth Huhn, vice president of labor relations at Deere, said in an internal email that his company should look at the alternatives to providing health benefits, which “would amount to denying coverage and just paying the penalty,” and that he felt he already had the ability to make this change under his company’s labor agreement.

Caterpillar felt it would have to give “serious consideration” to the penalty option.

AT&T revealed that it spends $2.4 billion a year on coverage for its almost 300,000 active employees, a number that would fall to $600 million if AT&T stopped providing health care coverage and paid the penalty option instead.

(Caterpillar) could reduce its bill by over 70%, by Fortune’s estimate.

It’s these analyses — which show it’s a lot cheaper to “pay” than to “play” — that threaten to overthrow the traditional architecture of health care.

The full article contains links to documents supporting some of these assertions:

http://money.cnn.com/2010/05/05/news/companies/dropping_benefits.fortune/index.htm

Yesterday’s qotd message described measures in the Patient Protection and Affordable Care Act (PPACA) that would motivate employers to downgrade their health benefit programs to an actuarial value of 60 percent (the employees would pay an average of 40 percent of actual health care costs, in addition to their share of the insurance premium). Today’s message reveals that major employers are considering the option of dumping their health benefit programs altogether.

The government subsidies for plans purchased in the state exchanges are large enough to shift a major portion of the costs of the health benefit programs from the employers/employees to the taxpayers. Further, the subsidized Silver-tier plans in the exchanges provide an actuarial value of 70 percent, resulting in greater benefits than the downgraded plans would have, at a net lower cost for the employers.

Unfortunately, neither is a great deal for the employees and their families. Employer-sponsored plans currently have a typical actuarial value of 80 percent, and sometimes as high as 90 or 95 percent. PPACA exchange plans will shift more costs to those who need health care by reducing the effective actuarial value to 70 percent for those with incomes over 250% FPL (federal poverty level), and those with incomes over 400% FPL would have no out-of-pocket limits to protect them.

Regardless, the complex structure of PPACA will result in worse coverage for employees than many of them currently have. This was the result of Congress and the Obama administration insisting that reform be built on our existing employer-based system, while facing the complex logistical problems of balancing the flow of money between individuals, employers, the government, the insurers, and the providers of health care.

It would have been far simpler, less expensive, and much more effective to establish a single financing pool, equitably-funded through the tax system, while providing significantly greater value in health care purchasing for all of us through a publicly-owned, publicly-administered, beneficent monopsony – an improved Medicare for all. We can still do it.

February 9, 2010

President Barack Obama
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500

Dear Mr. President,

Physicians for a National Health Program, an organization of 17,000 doctors who support single-payer national health insurance, respectfully requests that you invite one or more of our representatives to participate in your White House health care session on Feb. 25.

We note that in your call for the meeting you urged Republicans, Democrats and health policy experts to gather, go over all the options and “walk through them in a methodical way so that the American people can see and compare what makes the most sense.”

We would like to offer several of our members as health policy experts for this important task.

As you may know, two key research studies that helped drive the health reform process forward this past year – one in the American Journal of Public Health that found 45,000 deaths annually are linked to lack of health insurance, another in the American Journal of Medicine that found 62 percent of personal bankruptcies are linked to medical bills and illness – were the work product of Harvard Medical School research teams guided by PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler.

Drs. Himmelstein and Woolhandler, who are also primary-care physicians in Cambridge, Mass., have had several other groundbreaking studies published in our nation’s leading medical journals, including one in the New England Journal of Medicine that shows administrative costs consume 31 percent of U.S. health spending, most of it unnecessary. They have also frequently testified before Congress on their research. We urge that you invite them to participate in the Feb. 25 meeting.

The presence of Dr. Margaret Flowers, our congressional fellow, would also enhance the meeting. Dr. Flowers, a Maryland pediatrician, has met with numerous members of Congress and testified before two congressional committees last year about the urgent need for single-payer health reform.

Finally, we ask that you invite our president, Dr. Oliver Fein, to participate. Dr. Fein, an internist and professor of clinical medicine and clinical public health in New York City, attended the March 5 White House Summit on health care. He is a past vice president of the American Public Health Association.

Detailed biographies and contact information for each of these doctors are available upon request. Please feel free to call me (312-782-6006) or e-mail me (info@pnhp.org) should you need any additional information.

Sincerely,

Ida Hellander, M.D.
Executive Director

There are numerous ways to help groups already on the ground in Haiti. One of the best, Partners In Health, founded by Dr. Paul Farmer and several others, has been operating in the country since 1987. PIH operates clinics in Port au Prince and other major Haitian cities. With hospitals and a highly trained medical staff in place, Partners In Health is already bringing medical assistance and supplies to areas that have been hardest hit. Donations to PIH to help earthquake relief efforts will be quickly routed to the disaster.

You can donate online to the Partners in Health effort via this link:
http://www.pih.org/home.html

or send your contribution to:
Partners In Health,
P.O. Box 845578
Boston, MA 02284-5578

Trained medical staff are also urgently needed.

Nurses who want to volunteer in Haiti are being coordinated by the Registered Nurse Response Network (RNRN), a project of the 150,000-member National Nurses United (NNU), formed last month through the unification of the California Nurses Association and other nurses unions.  RNRN is hoping to have nurse volunteers on the ground in Haiti within the next few days and is coordinating with Haitian nurses on the effort.

Details are still being worked out, but those able to support the efforts of these nurses can get involved via:

* www.NationalNursesUnited.org to sign up to volunteer or donate
* @NationalNurses on twitter or by following: #haitiRN
* Call the RNRN hotline: 1-800-578-8225

The RNRN may also be able to help direct physicians who would like to volunteer in the recovery effort. Groups like Doctors without Borders are among those who are already treating victims.

Dr. Quentin Young, national coordinator of Physicians for a National Health Program, has written a foreword to a new book by Dr. Dani Filc of Israel.

Young writes (excerpt):

“As I sat down to read Dani Filc’s ‘Circles of Exclusion,’ I expected to learn a great deal about the Israeli health care system. What I did not expect was to find that this tiny country enmeshed in a seemingly intractable conflict in the Middle East would have so many lessons for the world’s most powerful nation – the United States.

“Several pages into this courageous book, it became clear that the issues Dr. Filc describes hold great relevance for those grappling with America’s ongoing health care crisis. The crisis in Israel and that in the United States are the result of the impact of neoliberal market policies that are currently being imposed on health care throughout the globe.

“In both countries we see a decline in concern and funding for public health and the exclusion of the poor racial and ethnic minorities from increasingly privatized health care systems in which the survival of profit-making enterprises seems to be the paramount concern. …

“For a public health advocate like myself, the message of this book is crystal clear. Obsessive preoccupation with free-market formulas are intensifying social and health care problems in industrialized countries, not resolving them. Of course, Filc shows us how this has happened is Israel, which because of its history puts a very specific spin on the problems of the poor, the old, racial and ethnic minorities, and the new migrant working class that crisscrosses the globe. Nonetheless, in Israel and elsewhere, preoccupations with profit are crowding out concerns for the classical social determinants of health and, as Dr. Filc points out over and over again, are not saving money but actually wasting it.”

The editors at Cornell University Press write:

“In its early years, Israel’s dominant ideology led to public provision of health care for all Jewish citizens-regardless of their age, income, or ability to pay. However, the system has shifted in recent decades, becoming increasingly privatized and market-based. In a familiar paradox, the wealthy, the young, and the healthy have relatively easy access to health care, and the poor, the old, and the very sick confront increasing obstacles to medical treatment.

“In ‘Circles of Exclusion,’ Dani Filc, both a physician and a human rights activist, forcefully argues that in present-day Israel, equal access to health care is constantly and systematically thwarted by a regime that does not extend an equal level of commitment to the well-being of all residents of Israel, whether Jewish, Israeli Palestinians, migrant workers, or Palestinians in the Occupied Territories.

“Filc explores how Israel’s adoption of a neoliberal model has pushed the system in a direction that gives priority to the strongest and richest individuals and groups over the needs of society as a whole, and to profit and competition over care. Filc pays special attention to the repercussions of policies that define citizenship in a way that has serious consequences for the health of groups of Palestinians who are Israeli citizens — particularly the Bedouins in the unrecognized villages — and to the ways in which this structure of citizenship affects the health of migrant workers.

“The health care situation is even more dire in the Occupied Territories, where the Occupation, especially in the last two decades, has negatively affected access to medical care and the health of Palestinians. Filc concludes his book with a discussion of how human rights, public health, and economic imperatives can be combined to produce a truly equal health care system that provides high-quality services to all Israelis.”

For Immediate Release

Dec. 22, 2009

Contact:
David Himmelstein, M.D.
Steffie Woolhandler, M.D., M.P.H.
Oliver Fein, M.D.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

A national organization of 17,000 physicians who favor a single-payer health care system called on the U.S. Senate today to defeat the health care legislation presently before it and to immediately consider the adoption of an expanded and improved Medicare-for-All program.

While noting that the Senate bill includes some “salutary provisions” like an expansion of Medicaid, increased funding for community clinics and the curbing of some of the worst practices of the private insurance industry, the group says the negatives in the bill outweigh the positives.

The negatives, the group says, include the individual mandate requiring that people buy private insurance policies, large government subsidies to private insurers, new restrictions on abortion, the unfair taxing of high-cost health plans, and cuts of $43 billion in Medicare payments to safety-net hospitals. Moreover, at least 23 million people will remain uninsured when the plan finally takes effect, they said.

“We have concluded that the Senate bill’s passage would bring more harm than good,” the group said in a statement signed by its president, Dr. Oliver Fein, and two co-founders, Drs. David Himmelstein and Steffie Woolhandler.

Addressing the Senate in an open letter, they write: “We ask that you defeat the bill currently under debate, and immediately move to consider the single-payer approach – an expanded and improved Medicare-for-All program – which prioritizes the advancement of our nation’s health over the enhancement of private, profit-seeking interests.”

The full statement appears below.

To the Members of the U.S. Senate:

It is with great sadness that we urge you to vote against the health care reform legislation now before you. As physicians, we are acutely aware of the unnecessary suffering that our nation’s broken health care financing system inflicts on our patients. We make no common cause with the Republicans’ obstructionist tactics or alarmist rhetoric. However, we have concluded that the Senate bill’s passage would bring more harm than good.

We are fully cognizant of the salutary provisions included in the legislation, notably an expansion of Medicaid coverage, increased funds for community clinics and regulations to curtail some of private insurers’ most egregious practices. Yet these are outweighed by its central provisions – particularly the individual mandate – that would reinforce private insurers’ stranglehold on care. Those who dislike their current employer-sponsored coverage would be forced to keep it. Those without insurance would be forced to pay private insurers’ inflated premiums, often for coverage so skimpy that serious illness would bankrupt them. And the $476 billion in new public funds for premium subsidies would all go to insurance firms, buttressing their financial and political power, and rendering future reform all the more difficult.

Some paint the Senate bill as a flawed first step to reform that will be improved over time, citing historical examples such as Social Security. But where Social Security established the nidus of a public institution that grew over time, the Senate bill proscribes any such new public institution. Instead, it channels vast new resources – including funds diverted from Medicare – into the very private insurers who caused today’s health care crisis. Social Security’s first step was not a mandate that payroll taxes which fund pensions be turned over to Goldman Sachs!

While the fortification of private insurers is the most malignant aspect of the bill, several other provisions threaten harm to vulnerable patients, including:

* The bill’s anti-abortion provisions would restrict reproductive choice, compromising the health of women and adolescent girls.

* The new 40 percent tax on high-cost health plans – deceptively labeled a “Cadillac tax” – would hit many middle-income families. The costs of group insurance are driven largely by regional health costs and the demography of the covered group. Hence, the tax targets workers in firms that employ more women (whose costs of care are higher than men’s), and older and sicker employees, particularly those in high-cost regions such as Maine and New York.

* The bill would drain $43 billion from Medicare payments to safety-net hospitals, threatening the care of the 23 million who will remain uninsured even if the bill works as planned. These threatened hospitals are also a key resource for emergency care, mental health care and other services that are unprofitable for hospitals under current payment regimes. In many communities, severely ill patients will be left with no place to go – a human rights abuse.

* The bill would leave hundreds of millions of Americans with inadequate insurance – an “actuarial value” as low as 60 percent of actual health costs. Predictably, as health costs continue to grow, more families will face co-payments and deductibles so high that they preclude adequate access to care. Such coverage is more akin to a hospital gown than to a warm winter coat.

Congress’ capitulation to insurers – along with concessions to the pharmaceutical industry – fatally undermines the economic viability of reform. The bill would inflate the already crushing burden of insurance-related paperwork that currently siphons $400 billion from care annually. According to CMS’ own projections, the bill will cause U.S. health costs to increase even more rapidly than presently, and budget neutrality is to be achieved by draining funds from Medicare and an accounting trick – front-loading the new revenues while delaying most new coverage until 2014. As homeowners seduced into balloon mortgages have learned, pushing costs off to the future is neither prudent nor sustainable.

We ask that you defeat the bill currently under debate, and immediately move to consider the single-payer approach – an expanded and improved Medicare-for-All program – which prioritizes the advancement of our nation’s health over the enhancement of private, profit-seeking interests.

Oliver Fein, M.D., President
David U. Himmelstein, M.D., Co-founder
Steffie Woolhandler, M.D., M.P.H., Co-founder
Physicians for a National Health Program

************

Physicians for a National Health Program is an organization of 17,000 doctors who advocate for single-payer national health insurance. To contact a physician-spokesperson near you, visit www.pnhp.org/stateactions or call (312) 782-6006.

The New England Journal of Medicine (NEJM) has had a decades-old policy of financial disclosure by authors of editorials in order to “prevent financial interests from infringing on the editorial content of the Journal.”

This policy was grossly violated when the editors of the NEJM recently chose to publish an opinion piece by Senator Max Baucus titled “Doctors, Patients, and the Need for Health Care Reform” (Vol. 361:1817-1819, Nov. 5, 2009, No. 19) that included a statement by the author that he had no financial interests to disclose.

In the past year alone, Sen. Baucus has received payments from drug and health insurance companies many times in excess of the $10,000 limit which the Journal recognizes as significant to alter an author’s credibility. By failing to disclose those contributions to Journal readers, Sen. Baucus and the editors of the NEJM have violated their own code of ethics and disclosure meant to support the veracity of opinions and data presented in their journal.

Disclosure of the senator’s directly or indirectly received payments from health insurance and pharmaceutical companies would help readers understand why Sen. Baucus continues to support a government-subsidized, high-overhead, low-outcome private insurance industry operating parallel to and within Medicare insurance.

Disclosure of the senator’s receipt of such “contributions” from the health care sector might demonstrate why he supports a private health insurance industry that siphons away, via administrative overhead, hundreds of billions of dollars annually from physician subscribers to the NEJM, patients, clinics, therapists, and pharmacies.

In addition to failing to disclose in the NEJM the monies he has received from pharmaceutical and health insurance companies, Sen. Baucus failed to inform readers of his personal and his Senate Finance Committee’s continued support for (or acquiescence to) the following policies:

* A federal exemption for private health insurance companies from antitrust regulations.

* A prohibition on Medicare insurance establishing a drug formulary through competitive bidding.

* No federal grants to develop a single EMR and billing system for physicians, hospitals and therapists which would reveal clinical, preventative and surgical outcomes. Outcome revelations would crush the health insurance companies, and allow for free-market competition among doctors and hospitals based on quality and efficiency.

* Protection of private health insurance companies from medical malpractice lawsuits via federal ERISA laws.

* Part D taxpayer subsidies to health insurance and drug corporations.

* Medicare Advantage taxpayer subsidies to health insurance companies.

* Reckless and negligent medical rationing by private health insurance companies via their non-physician employees.

* A government ban on collective bargaining by physicians.

* An inability of Medicare to enlarge its limited risk pool beyond that of the oldest, sickest and most physically disabled citizens of our nation.

* Personal bankruptcies due to a medical illness.

* No real change in malpractice reform. Real malpractice reform would allow internists and family practitioners to fulfill their role as primary care physicians efficiently and productively, tackling dynamic illnesses without prematurely referring their sicker patients to expensive specialists without medical benefit.

By allowing Sen. Baucus to express his opinion without a comprehensive disclosure of the large sums he has received from health insurance and pharmaceutical companies or of his continued support of current health care policies, the editors of the NEJM have surrendered their objective status as an advocate of integrity in research and patient care.

Sincerely,

Howard A. Green, M.D., FACP, FAAD, FACMS

By A.R. Strobeck Jr.

In “The Cancer Generation,” Dr. John Geyman, physician and professor emeritus of family medicine at the University of Washington, focuses on the baby boomer generation in the United States and the virtual tsunami of cancer cases that is expected to hit this 79.5-million-member demographic as more of its members move into their “golden years.”

Geyman says he aims to examine “the changing landscape of cancer in the U.S., including the extent to which the marketplace fails patients with cancer care.” He takes a hard look at how well the present state of cancer care – particularly the financing of medical services – measures up to the task of providing quality, compassionate care to those who need it.

While he draws upon the latest academic research and the book is heavily footnoted, the material is presented in a popular, accessible way, including with the abundant use of tables and graphs.

The picture he draws is not pretty. The author believes that the outlook for cancer care is bleak, largely due to the unregulated “free market” economic policies that have come to dictate both access to, and delivery of, health care in the U.S. These policies have given rise to an astronomical increase in the costs of cancer care, with treatment costs are now rising by 20 percent each year. The rising costs are putting effective care out of reach of millions.

This problem is expected to worsen, the author says, noting that the Institute of Medicine projects the number of cancer cases will double between 2000 and 2050. Meanwhile, the annual cost of treating cancer is projected to reach $1.1 trillion by 2023, more than five times what we spend today.

As a result, the aging of the U.S. population “will lead to an increasing cancer burden, both for individuals and their families as well as for the health care system itself.”

Geyman acknowledges that treatments for cancer have improved, and today’s care can be effective in many cases. He points to the dramatic increase in the survival rate among children diagnosed with cancer, for example.

But lack of health insurance, or poor quality insurance, prevents people from getting access to and obtaining proper care. The chief culprit here, he says, is the private health insurance industry, which is more concerned with increasing its profits than in assuring access to care.

More generally, however, he believes that our present market-driven health care system cannot meet the coming surge in cancer cases without drastic changes in its structure, access, delivery and methods of financing.

Geyman sees a blind faith in technology in the U.S. as fueling an explosion of new technologies, even though there is much uncertainty as to the safety and efficacy of these innovations. Unfortunately, he asserts, due to the high stakes that come with cancer, patients facing it are “especially vulnerable to accepting treatment at whatever the risks or costs.” Thus the marketplace is “setting cancer policy by default,” i.e. most of our health care dollars are going into treatment and far too little into prevention.

Cancer survivors face special challenges, he writes. They are less likely to be employed. They face three kinds of barriers to care thrown in their way by private insurance: availability, affordability and adequacy. And if these barriers are not enough, private insurance companies sometimes will go to even greater lengths to deny coverage to those afflicted.

Survivors lucky enough to have insurance face much higher co-payments. In addition, insurance firms try to cap coverage or otherwise place limits on the amount of treatment. As a result, a cancer diagnosis is often a prelude to financial crisis and bankruptcy.

Cancer survivors without insurance often find it difficult to see a doctor or to have a regular source of care. Geyman notes that it is no wonder that uninsured and Medicaid patients often have cancer at a more advanced stage when it is diagnosed. In addition, most cancer survivors often have serious co-morbidities such as heart disease or diabetes, which also go untreated at a disproportionately higher rate.

Geyman argues that everyone needs accessibility to doctors if the mortality rate of cancer is to be reduced. Unfortunately, the policies of the private health insurance industry are heading in the opposite direction, leading to uncontrolled inflation of costs; growing unaffordability of premiums; decreasing levels of coverage; a bloated bureaucracy, contributing to the waste of 31 cents of every U.S. health care dollar on administrative costs; a shrinking market of only 59 percent of employers now offering health insurance; ineffective state and federal regulation; and growing insecurity and hardship in the general population.

Racial disparities also continue to take a heavy toll: for example, cancer mortality rates are 35 percent higher for African Americans than whites.

What’s his prescription for a cure? As step No. 1, Geyman recommends establishing a public health insurance system such as single-payer Medicare for All. Such a system would provide health care services “based on medical need, not ability to pay, ” and would “eliminate much of the inefficiency and waste of the private insurance industry and actually cost employers and individuals less than we are already paying for insurance and health care.”

He outlines additional measures like establishing a national, evidence-based clinical effectiveness program; more funding for cancer research; and the strengthening of the nation’s cancer workforce, especially in primary care and geriatric oncology.

Finally, Geyman reminds us of the ethical issues surrounding cancer care, citing Dr. Martin Luther King Jr., when he said, “Of all forms of inequality, injustice in health care is the most shocking and most inhuman…. Although social change cannot come overnight, we must always work as though it were a possibility in the morning.”

Reading and acting on this book will help bring about that better day.

A.R. Strobeck Jr. worked for many years in health care administration. He resides in Chicago.

By Diana Stritzel

I just wanted to say that I really enjoy reading your articles and feedback on what’s going on about health care in the U.S. I don’t remember how I found your list and subscribed to it, but I find it really useful to learn more about the system.

Being German by birth, I find it really awful what people here in the U.S. are being subjected to just to go and see a doctor. I’ve had people at my workplace telling me how horrible it must be that I don’t have the choice of doctor in my country of origin. I was like …What? I never had so many problems in any other country I’ve been in before.

The U.S. is the worst. (I’ve lived in United Kingdom, Italy, New Zealand and Australia.) My employer provides coverage, and not a bad one, as I’ve been told. Now, I’ve had nothing but trouble with the insurer (Aetna). I was on PPO plan before, but now I moved to my employer’s state (California) and I’m covered on Aetna’s HMO plan.

But for all plans I have to go online or call them first, and find a doctor which is in the network, so that Aetna covers it. In Europe I never had that problem, I can go to any doctor anywhere and I don’t need to ask or check with insurance first.

Then there’s the administrative effort required. Every time I go to a doctor, I have to fill out so much paperwork, and sign three statements that I will pay for all charges incurred in case my insurance doesn’t pay. As if that wouldn’t make you feel more miserable than you already are (seeking a doctor in the first place).

And after all that, I’ve still had bills coming to my house, which led me to call my insurance company and they told me I’ll have to pay these, because my doctor requested tests from a lab which is not in Aetna’s network. So now I have to be paranoid about each test the doctor wants to do, and ask the doctor to please use a lab which is covered by Aetna. Outrageous!

After my move to California I was unlucky enough to be in need of emergency room. They suggested I go for a follow-up in a couple of days. Since I hadn’t been to my “PCP” yet, and I live in San Diego, whereas Aetna send me a coverage card which stated that my PCP is in Los Angeles, when trying to change my PCP to one in San Diego I failed in three attempts (one online, and two by phone). Once I was in the doctor’s practice, they called to verify with Aetna that this was changed (because I only had the card which stated the L.A. doctor’s name), and Aetna’s employees said no. (I had been on the phone with them forever until they finally said yes, we’ve changed it.)

The doctor suggested I pay for the visit and claim it back, but I had learned from before (my PPO plan) that Aetna will find a way to never pay these back to me. So again I called them up and asked for changing my doctor. I was wondering why they added a doctor in L.A. in the first place as they had my correct address in San Diego.

Anyway, after subjecting me to lots of useless questions like “When are you planning to change your PCP again?” (which made me wanna cry…. I didn’t choose that doctor!), finally they said that they changed it, and I made them give verbal confirmation to the practice right away, so I could finally see a doctor.

I haven’t received any bills yet, but I’m wondering when they might come.

I think the system as a whole is really awful. Hard to see any light at all, with politicians taking the bribes from insurance companies and such statements as Obama’s below. [Editor’s note: the reference is to President Obama’s comment that moving to a single-payer system would be disruptive.] I don’t understand why Americans don’t fight more for health care, which is one of the most important things to have. The feeling of security that comes with a health care system like in the U.K. (where I studied and lived many years) is just not replaceable.

I for my part wish you all the best, and I do hope you will not stop fighting for your right to health care (yes, in my opinion it is a right which every human should have).

Thanks for your articles and the awareness you bring to this topic. I’m following Ralph Nader as well, and I do hope that despite all the ridiculing your media does to him, that maybe one day someone will listen and change the system. I hope I’ll see the day, I know for sure that I won’t be living in U.S. by then though.

Thanks and keep going!